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2. Section I
4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Home Phone Number
16. I believe the discrimination I experienced was based on (check one):

    1. Title VI
    2. ADA
20. Section II
22. Are you filing this complaint on your own behalf? *

    1. Yes
    2. No
24. *If you answered “yes” to this question, go to Section III.
26. If not, please supply the name and relationship of the person for whom you are complaining.
28. First Name
29. Last Name
30. Relationship
32. Please explain why you have filed for a third party:
34. Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.

    1. Yes
    2. No
38. Section III
40. I believe the discrimination I experienced was based on (check all that apply):

    1. Race
    2. Color
    3. National Origin
    4. Disability
42. ShapeDate of Alleged Discrimination (Month, Day, Year): *
    ShapeDate of Alleged Discrimination (Month, Day, Year):
44. Explain as clearly as possible what happened and why you believe you were discriminated against. List names and contact information for all those involved, including witnesses.
48. Section IV
50. Have you previously filed a Discrimination Complaint with this agency?

    1. Yes
    2. No
52. If yes, please provide any reference information regarding your previous complaint.
56. Section V
58. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?

    1. Yes
    2. No
60. If yes, check all that apply:

    1. Federal Agency: 
    2. Federal Court:
    3. State Agency:
    4. State Court:
    5. Local Agency: 
62. Please provide information about a contact person at the agency/court where the complaint was filed.
64. First Name
65. Last Name
67. Title
68. Agency
69. Phone Number
71. Address
73. City
74. State
75. Zip Code
79. Section VI
81. Name of agency complaint is against
82. Name of person complaint is against
83. Title
85. Location
86. Telephone Number (if available)
88. You may attach any written materials or other information that you think is relevant to your complaint by adding those to the Coordinator’s email. Your signature and date are required below:
90. Written materials or other information you think is relevant to your complaint
92. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
94. Electronic Signature
95. Date
    Date
97. This form can be submitted online, in person at the address below, or via email below:

    City of Portland, TN

    100 South Russell St. Portland. Tennessee 37186

    City Hall: 615-325-6776

    www.cityofportlandtn.gov

    Email TITLE VI Coordinator: TitleVIcoordinator@cityofportlandtn.gov  

    Email ADA Coordinator: ADAcoordinator@cityofportlandtn.gov 

    
    
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99. 1. Receive an email copy of this form.
100. Email address

     This field is not part of the form submission.

101. Submit

* indicates a required field